MICROVASCULAR DECOMPRESSION FOR TRIGEMINAL NEURALGIA.

BACKGROUND: Trigeminal Neuralgia (TGN) is the most frequently diagnosed type of facial pain. In idiopathic type of TGN it is caused by the neuro-vascular conflict involving trigeminal nerve. Microvascular decompression (MVD) aims at addressing this basic pathology in the idiopathic type of TGN. This study was conducted to determine the outcome and complications of patients with idiopathic TGN undergoing MVD. METHODS: In a descriptive case series patients with idiopathic TGN undergoing MVD were included in consecutive manner. Patients were diagnosed on the basis of detailed history and clinical examination. Retromastoid approach with craniectomy was used to access cerebellopontine angle (CP-angle) and microsurgical decompression was done. Patients were followed up for 6 months. RESULTS: A total of 53 patients underwent MVD with mean age of 51.6±4.2 years and male predominance. In majority of cases (58.4%) both Maxillary and Mandibular divisions were involved. Per-operatively superior cerebellar artery (SCA) was causing the neuro-vascular conflict in 33 (62.2%) of the cases, anterior inferior cerebellar artery (AICA) in 6 (11.3%) cases, both CSA and AICA in 3 (5.6%) cases, venous compressions in only 1 (1.8%) patient and thick arachnoid adhesions were seen in 10 (18.9%) patients. Postoperatively, 33 (68%) patients were pain free, in 14 (26.45%) patients pain was significantly improved whereas in 3 (5.6%) patients there was mild improvement in symptoms. Three (5.6%) patients did not improve after the primary surgery. Cerebrospinal fluid (CSF) leak was encountered in 7 (13.2%) patients post-operatively, 4 (7.5%) patients developed wound infection and 1 (1.8%) patient developed aseptic meningitis. Three (5.6%) patients had transient VII nerve palsy while one patient developed permanent VII nerve palsy. CONCLUSION: MVD is a safe and effective surgical option for treating patients with idiopathic TGN with better surgical outcome and fewer complications.

Lumbar disc herniation in patients with chronic backache.

BACKGROUND: Low back pain with or without lower extremity pain is the most common problem among chronic pain disorders with significant economic, social, and health impact. This study was conducted to determine the frequency of lumbar disc herniation and its different levels, among patients with chronic backache. METHODS: This cross sectional study was conducted in the department of Neurosurgery, Ayub Medical College Abbottabad from January 2011 to January 2013. All the patients presenting with chronic low backache of either gender above the age 14 years were included in the study. Magnetic resonance imaging (MRI) was done in all the patients included in the study to look for lumbar disc herniation. RESULTS: A total of 477 patients with chronic low backache were included in the study out of which 274 (57.4%) were males. Age of the patients ranged from 19 to 75 (39.92 +/- 12.31) years. Out of 477 patients 38 (7.9%) had significant radiological evidence of disc prolapse at lumbar vertebral levels, with 26 (9.5%) males and 12 (5.9%) females. Among these 38 patients with inter-vertebral disc, 20 (52.6%) of patients had disc herniation at L5-S1, 15 (39.5%) at L4-L5, 2 (5.26%) cases at L3-L4 level and only one case (2.6%) had the involvement of L2-L3 level. No cases of L1-L2 disc prolapse were found. CONCLUSION: Patients with chronic backache can have inter-vertebral lumbar disc prolapsed disease. Middle age group are more affected by lumbar disc disease especially at the lower lumbar regions.

Outcome of transcranial repair of traumatic CSF rhinorrhea.

BACKGROUND: Traumatic brain injury represents a significant cause of mortality and permanent disability in the adult population. Posttraumatic CSF rhinorrhea is one of the conditions most strongly associated with severe brain injury. Knowledge on the natural history of the illness and the outcomes of patients with transcranial subfrontal approach for posttraumatic CSF rhinorrhea approach may help the neurosurgeon in the decision-making process. This study was conducted to analyse the outcome of trans-cranial sub-frontal approach for traumatic CSF rhinorrhea, with duroplasty and fibrin glue. METHODS: This study was carried out in the Department of Neurosurgery, Ayub Medical College, Abbottabad from Jan 2007 to Jun 2011. All patients undergoing trans-cranial sub-frontal repair of traumatic CSF fistulas were included. Where possible primary dural repair was performed under hypotensive general anaesthesia and in the cases where it was not possible, graft was used. This was followed by application of fibrin glue at the repaired site. Graft materials used in this study were taken from fascia lata, pericranium, and temporalis fascia. RESULTS: Out of 27 patients 21 were men and 6 were women. Age of the patients ranged from 17 to 56 (34.5 +/- 4.6) years. Main causes of trauma were road traffic accidents (23, 85%), fall from height (3, 11%), and assaults (1, 4%). In 23 (85%) cases no CSF leak was observed in immediate postoperative period as well as during the follow-up visits while in 3 (11%) cases additional lumber punctures were required to augment the repair. One patient failed to respond to surgery and lumbar drainage. CONCLUSION: The CSF rhinorrhea is commonly seen in patients with anterior skull fractures secondary to head injury. Initially conservative trail should be given to the patients, if it fails then on-lay dural technique followed by fibrin glue application through transcranial approach has good outcome with less chances of complications.

Predisposing factors, clinical presentation and outcome of repeated aspiration in cerebral abscess through a drainage tube in situ.

BACKGROUND: Cerebral abscess is a serious and life threatening complication of several diseases. Aspiration of the abscess cavity versus excision of capsule are still in debate for the capsulated, large, superficially located abscesses especially in patients with poor surgical fitness. The objective of this study was to look for the clinical presentation and outcome of patients with repeated aspiration in cerebral abscess through a drainage tube in situ. METHODS: This prospective study was conducted in Department of Neurosurgery, Ayub Medical College, Abbottabad from Jan 2010 to Jun 2011. Twenty-three patients with age ranges 6-21 years who had large, solitary, capsulated, superficially located abscesses, were included in this study. These patients had poor American Society of Anaesthesiologists (ASA) grading (grade III and IV). After thorough clinical examination and workup, patients were subjected to operative procedure. The procedure included placement of 8 size nasogastric tube in the abscess cavity through a single burr hole. Under strict aseptic conditions, repeated aspiration of pus was done through the drain daily for 2-4 days consecutively at intervals of 24 hours. The demographic data. predisposing factors, clinical presentation, and outcome of patients with repeated aspiration through drain placed in abscess cavity were recorded. Postoperatively, gadolinium enhanced CT-scan was done twice in the first month at the span of two weeks each, later on monthly for next 3 months. The CT-scans were reviewed for recurrence or any other possible intracranial complications. Patients were followed for duration of 3 to 6 months. RESULTS: The predisposing factors found were congenital heart disease in 7 (30.4%) patients, spread of contagious infections like mastoiditis/Chronic suppurative ottitis media in 5 (21.7%) patients, sinusitis in 2 (8.6%) patients, meningitis in 5 (21.7%) patients, septicemia in 3 (13.7%) patients, and penetrating cranial injury in 1 (4.34%) patients. In 16 (69.5%) patients presenting complaints were headache and vomiting, altered sensorium in 8 (34.7%) patients, hemiparesis in 9 (39.1) patients, aphasia in 3 (13.1%) patients, papillodema in 2 (8.7%) patients, and seizures in 1 (4.34%) patients. The abscess resolved in 19 (82%) of patients, recurrence occurred in 2 (8.7%) of patients, and death occurred in 2 (8.7%). CONCLUSION: Cerebral abscess is a life threatening condition requiring aggressive management measures. Aspiration of cerebral abscess with repeated aspiration through a drainage tube is a life saving in patients with poor ASA grade with low recurrence of abscess formation and low mortality.